Nursing Care For Patients with COPD PDF

THE CONCEPT OF OXYGENATION: NURSING CARE OF THE PATIENT WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) NR 1250/1610 Victoria Leonetti, MSN, RN Emily Raddell, MSN, RN COURSE STUDENT LEARNING OUTCOMES 1 2 3 4 Provide saf...

THE CONCEPT OF OXYGENATION: NURSING CARE OF THE PATIENT WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) NR 1250/1610 Victoria Leonetti, MSN, RN Emily Raddell, MSN, RN COURSE STUDENT LEARNING OUTCOMES 1 2 3 4 Provide safe, patient- Demonstrate Relate the impact of Explain management centered, evidence- intermediate levels of quality improvement of care concepts for based nursing care critical thinking & measures to improved adult patients guided by the Caritas clinical reasoning to patient care philosophy provide quality patient care  CONCEPT CHECK!!! OXYGENATION The mechanism that facilitates or impairs the body’s ability to supply oxygen to all cells of the body.  Persistent or recurrent obstruction of airflow Due to bronchoconstriction and inflammation OVERVIEW: Slowly alters structures of the respiratory system over time CHRONIC Periodic exacerbations with increased symptoms OBSTRUCTIVE Dyspnea and sputum production PULMONARY Irreversibly affects lung function DISEASE (COPD) Does not return to normal after exacerbation Not curable Includes components of both chronic bronchitis and emphysema  Results from repeated exposure to respiratory irritants 80% cases linked to cigarette smoking Damage to airway passages Increased mucous production Arrest in cilia action PATHOPHYSIOLOGY COPD: Excessive fluid accumulates in lung mucosal cells Edema results Narrowing of airway passages Airflow limitation, air trapping Hyperinflation of lungs Asthma often comorbid with COPD PATHOPHYSIOLOGY- CHRONIC BRONCHITIS Chronic Bronchitis oDisorder of excessive bronchial mucous secretion ­ Impaired cilia ­ Hypertrophy and hypersecretion in goblet cells and mucous glands ­ Chronic inflammation and obstruction of air flow oRecurrent infection common with chronic bronchitis oProductive cough lasting greater than/equal to 3 months in 2 consecutive years  PATHOPHYSIOLOGY- Emphysema EMPHYSEMA ­ Destruction of the walls of the alveoli ­ Results in enlargement of abnormal air spaces ­ Diffuse airway narrowing ¢Imbalance of lung proteases (enzymes secreted by neutrophils and macrophages) ­ Alpha 1 antitrypsin enzyme ¢Breakdown of elastin in lung tissues ­ Loss of elastic recoil ­ Reduces volume of air that is passively expired ¢Destruction of capillary beds ­ Surface area for alveolar-capillary diffusion reduced TWO SUB TYPES OF COPD Chronic Bronchitis Emphysema  oLeading cause of death, disability, and illness in the United States o4th leading cause of death oMortality rates nearly equal for men and women o10-24 million affected oCost for care near $90 billion ETIOLOGY- COPD oMost people with COPD: ­ Over age 50 ­ Current or former smoker with 20 pack/year history Primary causeà cigarette smoking (80% cases) Other causes: ­ Exposure to occupational irritants ­ Indoor and outdoor air pollution RISK FACTORS - COPD Frequent exposure SMOKING- the to smoke Air Pollution greatest risk factor (“secondhand”) Short-term exposure Long-term exposure Asthma may be a to high levels of to chemical irritants risk factor irritating substances Aging (loss of lung elasticity) PREVENTION - COPD Refrain from engaging in behaviors linked with etiology of the disease Don’t smoke or quit smoking! Decrease exposure to: Secondhand smoke Occupational respiratory irritants CLINICAL MANIFESTATIONS- COPD Presentation varies Manifestations absent or mild early in disease Initial symptoms long before changes in pulmonary function Chronic cough Sputum production No shortness of breath, dyspnea only on exertion As disease progresses: More severe dyspnea, even with mild activity Manifestations of chronic bronchitis, emphysema CLINICAL MANIFESTATION- CHRONIC BRONCHITIS Chronic bronchitis ­ Persistent productive cough, large amounts of thick, tenacious sputum ­ Cough typically in the morningà “smoker’s cough” ­ Adventitious lung soundsà loud rhonchi, wheezing ­ Cyanosis, dusky skin color ­ Dyspnea Symptoms often present for up to 10 years before seeking care **Productive cough lasting greater than/equal to 3 months in 2 consecutive years  Emphysema ­ Insidious onset (slow, no symptoms initially) ­ Dyspnea is first sign ­ Barrel chest ­ Air trapping, hyperinflation increase AP chest diameter ­ Tripod position (a position of sitting and leaning forward) ­ Pursed-lip breathing ­ Prolong expiratory phase ­ Chest pain, hypertension CLINICAL MANIFESTATIONS- ­ Dyspnea may progress to severe, even at rest EMPHYSEMA BARREL CHEST  Prolonged impairment of gas exchange: ­ Can lead to cardiac dysfunction ­ Right sided heart failure Caloric demand increases as effort to breathe increases ­ Weight loss ­ Anemia Anxiety Often thin, tachypneic, uses accessory muscles of respiration to CLINICAL MANIFESTATIONS- help breathe EMPHYSEMA  DIAGNOSTIC TESTS: PULMONARY FUNCTION TESTING (PFTS) FEV1 / FVC X 100= “FEV1 percent predicted” ­ 80% and above considered normal Decreased Forced Expiratory Volume in 1 second FEV-1 ( air expelled in first second) Decreased Forced Vital Capacity FVC (total air expelled) ­ Normally averages around 3 liters Increased Residual Volume RV (air remaining in the lungs)  Serum alpha1 antitrypsin levels Diagnostic Tests Screen for deficiency Arterial Blood Gas (ABG) DIAGNOSTIC during ACUTE EXACERBATION Evaluate gas exchange TESTS Pulse oximetry Monitor oxygen saturation of the blood Less than 95% Sputum cultures Complete Blood Count (CBC) with differential DIAGNOSTIC Polycythemia – indicated by increased hematocrit and hemoglobin TESTS Increased erythropoietin production in the kidneys Presence of a bacterial infection Chest X-Ray (CXR) Assess for presence of pulmonary infection What would you see? Flattened diaphragm Increased AP diameters (barrel chest) Cardiac enlargement  Lung transplantation Single Bilateral Good survival rates (1 year is nearly 80%, 5 year over 50%) SURGERY Lung reduction surgery Experimental intervention for advanced diffuse emphysema and lung hyperinflation Reduces overall volume of lung Reshapes lung Improves elastic recoil  Immunizations Pneumococcal pneumonia Influenza Broad-spectrum antibiotics if infection suspected PHARMACOLOGIC Bronchodilators Short and long acting beta 2 agonists (albuterol) THERAPY Anticholinergic medications (Ipratropium) Corticosteroids (prednisone- oral) Intravenous or oral Mucolytics, expectorants (guaifenesin) Helps break up and thin mucus  PHARMACOLOGIC THERAPY Oxygen Therapy: For severe, progressive hypoxemia Improves exercise tolerance, mental functioning, and quality of life Increases length of survival, reduces hospitalizations Used intermittently, at night, or continuously ­Greatest benefit in sever hypoxemia when used continuous Home therapy: liquid O2, compressed gas cylinders, or O2 concentrators Used with caution with chronic hypercarbia Monitor LOC and ABG values NONPHARMACOLOGIC THERAPY Percussion ­ Forceful striking of skin with cupped hands, mechanical percussion cups ­ Used to mechanically dislodge secretions from bronchial walls Vibration ­ Series of vigorous quiverings produced by hands flat on patient’s chest wall ­ Used after percussion to increase turbulence of exhaled air, loosening thick secretions Postural drainage ­ Drainage by gravity of secretions from lung segments ­ Lower lobes require more frequent drainage ­ May be preceded with bronchodilator or nebulizer therapy NONPHARMACOLOGIC THERAPY Smoking cessation ­ Can improve lung function after COPD develops ­ Prolong survival Avoid exposure to other airway irritants or allergens Remain indoors during periods of significant air pollution ­ Air-filtering systems or air-conditioning may be useful Pulmonary hygiene measures ­ Hydration, effective coughing, percussion, postural drainage ­ Cough suppressants usually ineffective ­ Avoid sedatives- cause retention of secretions NONPHARMACOLOGIC THERAPY Exercise Hydration Strength muscle used for Pursed-lip Abdominal Fluid intake Humidifiers breathing & breathing breathing ADLs  Promote airway clearance: ­Encourage fluid intake of >2000 mL/day (if permitted) ­Assess respiratory status every 1-2 hours or as indicated ­Monitor arterial blood gas (ABG) results IMPLEMENTATION: ­Daily weights, intake & output, assess mucous membranes and skin turgor NURSING ACTIONS ­Assist with coughing, deep breathing every 1-2 hours ­Refer to respiratory therapist (RT) for postural drainage, assist or perform as needed ­Administer expectorant, bronchodilator, corticosteroid medications as ordered ­Provide supplemental oxygen as ordered  Promoting activity and rest periods: ­Encourage semi-Fowler’s (30-45 degree) position IMPLEMENTATION: ­Encourage graded physical exercises, NURSING ACTIONS participation in pulmonary rehabilitation ­Instruct patient to pace activities and avoid overexertion ­Teach energy conservation techniques  Preventing or treating infection: ­Teach patient to prevent infection ­Avoid crowds, avoid contact with people who have upper respiratory infections IMPLEMENTATION: ­Take proper care and cleaning of home respiratory equipment NURSING ACTIONS ­Receive influenza and pneumonia immunizations! ­ Antibiotics administered as prescribed for COPD exacerbations  Promoting balanced nutrition: ­ Assess nutritional status ­ Observe, document food intake ­ Consult with dietitian ­ Encourage a high calorie, high protein diet ­ Place in seated or high-Fowlers for meals IMPLEMENTATION: ­ Frequent, small feedings NURSING ACTIONS ­ Encourage between-meal snacks ­ Rest before meals, use prescribed bronchodilator prior to eating ­ Wear prescribed oxygen during meals ­ Encourage family to bring food from home if permitted ­ Avoid alcohol  Promote family coping: ­Assess effect of illness on family ­Provide information, teaching about COPD ­Help family recognize hindering IMPLEMENTATION: behaviors ­Initiate care conference involving NURSING ACTIONS patient, family, healthcare team members ­Refer patient, family to support groups and pulmonary rehabilitation programs  Expected outcomes: ­Patient consistently maintains oxygen saturations >90% ­Patient modifies ADLs to reduce fatigue related to activity intolerance ­Patient demonstrates appropriate use of medications EVALUATION ­Recognition of the need for smoking cessation ­Reduction in anxiety, identifies relaxation techniques COPD is chronicà patient will need continual re-evaluation